​Health and Long-Term Care Reform: understanding practical issues

By now, there is no doubt about the provincial government’s commitment to health and long-term care reform.  Heaven knows, it has been promised with volumes written about it for 10 years or more.  To persons “on the street”, to ordinary physicians, to employees and their representatives the question remains:  What?  Where?  When?  How? Who?  By now, journalists should be seeing a pattern of change and the course of reform should be clear.  They are not!

I have searched for answers as to why so slow?  Why does the obvious require years?  The issues of the ALC patients in hospital have been obvious for many years yet there they are, occupying highly expensive beds needed to accommodate the huge backlog in surgical cases postponed largely due to the pandemic.   When you think you are seeing progress in moving a few to long term care, a new group come through the Emergency Department and back to square one all over again.

The skeptic would just put it down to the typical “resistance to change.”  As I have clarified in previous columns, there are many sources of resistance to change in health and long-term care, understandable by those who have worked in the system for their career and having had the requisite health administration education.  Those who are trained and experienced soon learn that all of us in the health professions resist change; the area in which skill and talent is needed is in figuring out how to manage through the web of resistance to change.  That requires knowledge, experience, skill, and leadership talent.

In New Brunswick we have other issues that challenge change in these sectors.  The culture of New Brunswick public sector management is one that seems very “hands-on” to the level of micro-management, as explained by some seasoned veterans.  I remember it well from my days working in the civil service in which our roles seemed a bit ambiguous.  What I could not understand was:  why does every thing that goes a bit sideways suddenly become a problem for the Minister or, in my case, my branch?  The answer seems to stem from the feeling in New Brunswick that because the province provides financial support to persons receiving care and who are in need, then that automatically means that if I am not happy and I call my MLA or the media, my unhappiness is now government’s problem.

The relationship between government and its service providers is not entirely master and servant, in reality.  We have an interesting collection of service providers in home care, adult residential facilities, hospitals, clinics, ambulance service and a host of other providers of service reimbursed in whole or in part from the public purse.

In the hospital sector, it has become convenient for government to be able to deflect much distress by acknowledging that government does not run hospitals; that is done through the very large health authorities.  Government’s role is to appoint some people to the boards, to approve submitted budgets, to appoint the CEO and the Board Chair; otherwise, the operation is “arms-length” although employees are considered to be members of Part 3 of the public service.

Long-term care is quite another story.  First you have home care service providers who hire staff and offer service to the public based on a service contract with government. There is some oversight and accountability but not at a micromanagement level.

In the Adult Residential Facilities, we have an entirely different arrangement in which homes (over 400 of them) are owned by a variety of persons and organizations, all subject to the same standards of operation, inspection, and occasionally investigation.  This sector has very rigid staffing formulae that are required and monitored to the letter, shift by shift.  These facilities are inspected and monitored by Coordinators in each of 8 regional offices in the province.  These are governed under the Family Services Act.

Then there are nursing homes that are mostly owned by local not-for-profit organizations and typically governed by a board of directors (except for those owned and operated by Shannex).  These are governed under the Nursing Home Act that prescribes the qualifications of Executive Directors and many operating requirements of the homes.  There are 68 such homes across the province and they provide superb care to what are referred to as Level 3 clientele, persons who require 24/7 access to nursing care.  Homes have an active sector association that represents their interests to government, unions, and the public.  They are not generally monitored at the same level as Adult Residential Facilities, although they are subject to annual inspections and some go the next step of being accredited by the Canadian Council of Health Facilities Accreditation.

In health and long-term care in New Brunswick, we have a variety of oversight relationships between government and service providers which may explain some of the issues described by other observers.  The variety of types and styles is no one’s fault but is simply a matter of evolution over time.

But part of health and long-term care reform is to figure all this out and create some commonality in relationships.

In having this conversation recently with a respected and seasoned “expert” the term “staying in our lanes” was referenced.  The phrase, used often in my hearing in recent years, refers to clearly defining the role of government, service providers, and sector associations.  With clarity that can, then, lead to better outcomes and clear understanding of “who’s on first?”

The 2016 movie classic Sully told the story of the 2009 incident in New York City when an airplane, with 155 people aboard, took off from the airport then hit some birds, disabling an engine and compromising its ability to fly.  The pilot, after communicating with the tower, chose to land the plane on the Hudson River despite expectations of the regulators that he had sufficient thrust to make it back to the airport.  Even though acclaimed a public hero for saving 155 people, the regulators were about to shatter his stellar career because he failed to follow orders.  Toward the end of the hearing, the pilot introduced evidence that only an experienced pilot would understand that showed taking the plane into the river was the only real option.  He remains a folk hero with reputation intact!

The point is that government’s job is to regulate; that means, prescribing the system into which they are prepared to invest money, describe the system they want, describe how it is to be paid for by government and recipients of service, set the standards, and administer a process by which performance of the system is measured and sustained.

The actual “flying of the plane” is the job of the airlines and the people they employ.  Everything they do is prescribed in detail both in legislation and regulation and there is a defined process for creating and regularly reviewing the regulations.

In New Brunswick, one aggravation has been that the NB Health Council has published volumes of reports and information year after year for over 20 years.  Each year its CEO goes on media interviews to describe the findings of the latest reports.   But somehow there is a disconnect between the superb work they do and the regulators in that nothing much seems to happen with that penetrating information. 

Regulators need to focus on regulation; service providers need to focus on service provision in accordance with standards.  And if all function in their lanes, the system should prosper and deliver great service.  Service operators do not regulate, and regulators do not manage.
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Ken McGeorge,BS,DHA,CHE is a retired career health care CEO, part time consultant, and columnist with Brunswick News; he is the author of Health Care Reform in New Brunswick and may be reached at kenmcgeorge44@outlook.com or www.kenmcgeorge.com